NCLEX-RN 100 QUESTIONS/ ANSWERS 100% CORRECT
ANSWERS AND RATIONALES /A+ GRADE ASSURED
• A nurse is caring for a client who is receiving intravenous potassium chloride.
Which finding should the nurse report immediately?
• Urine output of 30 mL/hour
• Serum potassium level of 3.8 mEq/L
• Complaints of muscle weakness
• Burning sensation at the IV site
**Answer: A. Urine output of 30 mL/hour**
• A client is prescribed furosemide (Lasix) for treatment of heart failure. Which
finding indicates a therapeutic effect of the medication?
• Decreased serum potassium level
• Increased blood pressure
• Weight gain of 2 pounds in 24 hours
• Decreased pedal edema
**Answer: D. Decreased pedal edema**
• The nurse is caring for a client with pneumonia. Which assessment finding
requires immediate intervention?
• Cough productive of greenish sputum
• Temperature of 100.4°F (38°C)
• Crackles heard on auscultation of the lungs
,• Oxygen saturation of 95%
**Answer: B. Temperature of 100.4°F (38°C)**
• A client with diabetes mellitus is admitted with diabetic ketoacidosis (DKA).
Which intervention should the nurse implement first?
• Administer regular insulin IV
• Assess blood glucose level
• Infuse 0.9% normal saline IV
• Check urine ketones
**Answer: C. Infuse 0.9% normal saline IV**
• A nurse is caring for a client receiving enteral tube feeding. Which action is most
important to prevent aspiration?
• Check residual volume before each feeding
• Elevate the head of the bed to 30 degrees during and after feeding
• Administer medications through the feeding tube
• Flush the feeding tube with water after each feeding
**Answer: B. Elevate the head of the bed to 30 degrees during and after feeding**
• The nurse is assessing a client who is receiving heparin therapy. Which finding
requires immediate action?
• Bruising at the injection site
• Prolonged partial thromboplastin time (PTT)
• Coffee-ground emesis
,• Blood pressure of 140/90 mmHg
**Answer: C. Coffee-ground emesis**
• A client is diagnosed with acute appendicitis and is scheduled for surgery. Which
finding requires immediate intervention?
• Reports of right lower quadrant pain
• Abdominal rigidity and guarding
• Temperature of 99.5°F (37.5°C)
• WBC count of 12,000/mmS
**Answer: B. Abdominal rigidity and guarding**
• A nurse is caring for a client with cirrhosis of the liver. Which dietary instruction
should the nurse provide?
• "Increase your intake of protein."
• "Limit your intake of carbohydrates."
• "Avoid foods high in sodium."
• "Restrict your fluid intake."
**Answer: C. "Avoid foods high in sodium."**
• A client is receiving chemotherapy and reports nausea and vomiting. Which
action should the nurse take first?
• Administer an antiemetic medication
• Offer the client clear liquids
• Assess the client's temperature
, • Change the client's position
**Answer: A. Administer an antiemetic medication**
• The nurse is caring for a client who has just had a stroke. Which assessment
finding requires immediate intervention?
• Blood pressure of 150/90 mmHg
• Facial drooping on one side
• Difficulty speaking
• Urinary incontinence
**Answer: C. Difficulty speaking**
• A client is prescribed atenolol (Tenormin) for hypertension. Which instruction
should the nurse include in the client's teaching?
• "Take your pulse daily."
• "Increase your intake of potassium-rich foods."
• "Stop taking the medication if you feel dizzy."
• "Avoid drinking grapefruit juice."
**Answer: D. "Avoid drinking grapefruit juice."**
• A nurse is caring for a client with a closed head injury. Which finding requires
immediate intervention?
• Decreased level of consciousness
• Sluggish pupil reaction to light
ANSWERS AND RATIONALES /A+ GRADE ASSURED
• A nurse is caring for a client who is receiving intravenous potassium chloride.
Which finding should the nurse report immediately?
• Urine output of 30 mL/hour
• Serum potassium level of 3.8 mEq/L
• Complaints of muscle weakness
• Burning sensation at the IV site
**Answer: A. Urine output of 30 mL/hour**
• A client is prescribed furosemide (Lasix) for treatment of heart failure. Which
finding indicates a therapeutic effect of the medication?
• Decreased serum potassium level
• Increased blood pressure
• Weight gain of 2 pounds in 24 hours
• Decreased pedal edema
**Answer: D. Decreased pedal edema**
• The nurse is caring for a client with pneumonia. Which assessment finding
requires immediate intervention?
• Cough productive of greenish sputum
• Temperature of 100.4°F (38°C)
• Crackles heard on auscultation of the lungs
,• Oxygen saturation of 95%
**Answer: B. Temperature of 100.4°F (38°C)**
• A client with diabetes mellitus is admitted with diabetic ketoacidosis (DKA).
Which intervention should the nurse implement first?
• Administer regular insulin IV
• Assess blood glucose level
• Infuse 0.9% normal saline IV
• Check urine ketones
**Answer: C. Infuse 0.9% normal saline IV**
• A nurse is caring for a client receiving enteral tube feeding. Which action is most
important to prevent aspiration?
• Check residual volume before each feeding
• Elevate the head of the bed to 30 degrees during and after feeding
• Administer medications through the feeding tube
• Flush the feeding tube with water after each feeding
**Answer: B. Elevate the head of the bed to 30 degrees during and after feeding**
• The nurse is assessing a client who is receiving heparin therapy. Which finding
requires immediate action?
• Bruising at the injection site
• Prolonged partial thromboplastin time (PTT)
• Coffee-ground emesis
,• Blood pressure of 140/90 mmHg
**Answer: C. Coffee-ground emesis**
• A client is diagnosed with acute appendicitis and is scheduled for surgery. Which
finding requires immediate intervention?
• Reports of right lower quadrant pain
• Abdominal rigidity and guarding
• Temperature of 99.5°F (37.5°C)
• WBC count of 12,000/mmS
**Answer: B. Abdominal rigidity and guarding**
• A nurse is caring for a client with cirrhosis of the liver. Which dietary instruction
should the nurse provide?
• "Increase your intake of protein."
• "Limit your intake of carbohydrates."
• "Avoid foods high in sodium."
• "Restrict your fluid intake."
**Answer: C. "Avoid foods high in sodium."**
• A client is receiving chemotherapy and reports nausea and vomiting. Which
action should the nurse take first?
• Administer an antiemetic medication
• Offer the client clear liquids
• Assess the client's temperature
, • Change the client's position
**Answer: A. Administer an antiemetic medication**
• The nurse is caring for a client who has just had a stroke. Which assessment
finding requires immediate intervention?
• Blood pressure of 150/90 mmHg
• Facial drooping on one side
• Difficulty speaking
• Urinary incontinence
**Answer: C. Difficulty speaking**
• A client is prescribed atenolol (Tenormin) for hypertension. Which instruction
should the nurse include in the client's teaching?
• "Take your pulse daily."
• "Increase your intake of potassium-rich foods."
• "Stop taking the medication if you feel dizzy."
• "Avoid drinking grapefruit juice."
**Answer: D. "Avoid drinking grapefruit juice."**
• A nurse is caring for a client with a closed head injury. Which finding requires
immediate intervention?
• Decreased level of consciousness
• Sluggish pupil reaction to light
